NEUROLOGIC ASSESSMENT OBJECTIVES: 1. ________________________________________________________________________________ 2. ________________________________________________________________________________ 3.


EQUIPMENTS: Reading material vials containing aromatic substances (e.g., vanilla and coffee) Opposite tip of cotton swab or tongue blade broken in half Penlight Tongue blade Cotton balls or cotton tipped applicators Reflex hammer

Snellen Chart vials containing sugar or salt two test tubes, one filled with hot water tuning fork

PERFORMANCE/RATIONALE/FINDINGS CHECKLIST PROCEDURE 1. See Standard Protocol before starting the procedure.







2. Assess for client’s cultural and educational background, values and beliefs. 3. Assess for sensory loss.

4. To test for client’s ORIENTATION, ask at least 5 questions and give one point for each as follows: What is the (1) year, (2) season, (3) date, (4) day, and (5) month. The perfect score is 5.

PROCEDURE 5. To test for client’s REGISTRATION: a. Ask first if you may test his memory. b. Then say the names of 3 unrelated objects clearly and slowly about 1 second for each (e.g., hospital, cucumber, school). c. After you have said all three, ask him to repeat them. First repetition determines his score (0-3) but keep saying them until he can repeat all 3, up to 6 trials. d. If patient does not eventually learn all three, recall cannot be meaningfully tested. 6. To assess for client’s ATTENTION and CALCULATION: a. Ask the patient to begin with 100 and count backwards by 7. Stop after 5 substractions (93, 86, 79, 72, 65) b. Score the total number of correct answers. c. If the patient cannot or will not perform this task, ask him to spell the word “WORLD” backwards. The score is the number of letters in correct order (e.g., dlrow=5; dlorw=3). 7. To assess for client’s ability to RECALL: a. Ask the patient if he can recall the three words you previously asked him to remember. b. Score 0-3.







PROCEDURE 8. To assess for client’s LANGUAGE thru the following: a. NAMING: Show the client a wrist watch and ask him what it is. Repeat for Pencil. Score 0-3. b. REPITITION: Ask the client to repeat the sentence after you. Allow only one trial. Score 0 or 1. c. 3-STAGE COMMAND: Give the client a piece of plain blank paper and repeat the command. d. READING: On a blank piece of paper print the sentence “CLOSE YOUR EYES” in letters large enough for the client to see clearly. Ask him to read it and do what it says. Score 1 point only if he actually closes his eyes. e. WRITING: Give the patient a blank piece of paper and ask him to write a sentence for you. Do not dictate a sentence; it is to be written spontaneously. It must contain a subject and verb and be sensible. Correct grammar and punctuation. f. COPYING. On a clean sheet of paper, draw intersecting pentagons, each side about 1 inch, and ask him to copy it exactly as it is. All 10 angles must be present and two must intersect to score 1 point. Tremor and rotation are ignored. Estimate the client’s level of sensorium along a continuum, from alert on the left to coma on the right.







9. To assess for client’s consciousness using the Glasgow Coma Scale, familiarize first the standardized table.

If there is eye opening upon hearing you speak. To test for the last category of GCS. To check for EYE OPENING RESPONSE: a. To check for the BEST VERBAL RESPONSE: a. Base from his answer. elicit pain by pressing at the client’s fingernail bed. Ask the client a simple question like. “What time of the day it is?” b. grade him with appropriate score for his response as follows: ORIENTED: 5 CONFUSED: 4 INAPPROPRIATE WORDS: 3 INCOMPREHENSIBLE SOUNDS:2 NONE: 1 12. try to close the door louder than the usual. the score is 1. greet the client and ask him a simple question. Press the client’s fingernail bed.PROCEDURE 10. When you enter the client’s room. the score is 4. Record BEST UPPER LIMB RESPONSE with the appropriate score as follows: OBEYS COMMANDS: 6 LOCALIZED PAIN: 5 FLEXION WITHDRAWAL: 4 ABNORMAL FLEXION: 3 ABNORMAL EXTENSION: 2 FLACCID: 1 RATIONALE 1 2 3 4 5 . the score is 3. b. c. If still with no response. If the client spontaneously opens his eyes. Score then is 2 if the client opens his eyes upon feeling the pain. BEST MOTOR RESPONSE to painful stimuli: a. If without response. 11. If still without response. b.

and tap the tendon. BICEPS REFLEX: Support the client’s forearm on yours. Dorsiflex the foot and tap the tendon. Strike the forearm directly about 2 to 3 cm above the radial styloid process.PROCEDURE 13. For the client in the supine position. Hold the foot in dorsiflexion. flex one knee and support that lower leg against the other leg so that it falls open. e. hold the client’s write across the chest to flex the arm at the elbow. b. ACHILLES REFLEX (Ankle jerk): Position the client with the knee flexed and the hip externally rotated. Alternately. BRACHIORADIALIS REFLEX: Hold the client’s thumb to suspend the forearms in relaxation. Add the client’s score based from EYE OPENING RESPONSE. f. RATIONALE 1 2 3 4 5 14. and strike the Achilles tendon directly. Strike the tendon directly just below the patella. Strike the triceps tendon directly just above the elbow. TRICEPS REFLEX: Tell the client to let the arm “just go dead” as you suspend it by holding the upper arm. d. To test for the client’s DEEP TENDON REFLEXES: a. BEST VERBAL RESPONSE. c. . Place your thumb on the biceps tendon and strike a blow on your thumb. QUADRICEPS REFLEX (Knee jerk): Let the lower legs dangle freely to flex the knee and stretch the tendons. and BEST MOTOR RESPONSE.

With the knees slightly bent. and feel it contract toward the stimulus. like an upside down J. ABDOMINAL REFLEX: Have the client assume a supine position. pull the skin to the opposite side. c. a wood applicator tip. With the client looking forward bring a wisp of cotton in from the side (to minimize defensive blinking) and lightly touch the cornea. RATIONALE 1 2 3 4 5 . not the conjunctiva. b. With the rflex hammer. ABDOMINAL REFLEX: Have the client assume a supine position. PLANTAR REFLEX: Position the thigh in slight external rotation. Use the handle end of the reflex hammer to stroke the skin. or the end of a split tongue blade to stroke the skin. with the knees slightly bent. use the handle end of the reflex hammer. When the abdominal wall is very obese. draw a light stroke up the lateral side of ths ole of the foot and inward across the ball of the foot. CORNEAL REFLEX: Remove any contact lenses.PROCEDURE 15. Move from the side of the abdomen toward the midline at both the upper and lower abdominal levels. To test for SUPERFICIAL REFLEXES: a. Move from the side of the abdomen toward the midline at both the upper and lower abdominal levels. d.

PROCEDURE 16. Instruct the client not to move the joint. b. place hand firmly against client’s upper jaw. the following scale is used: MUSCLE FUNCTION LEVEL No evidence of contractility Slight contractility. gravity eliminated Full range of motion with gravity Full range of motion against gravity. To assess for the MUSCLE STREGNTH: a.g. . c. with some resistance Full range of motion against gravity. an arm) to relax or hang limp. The extremity is supported and each limb is grasped moving it through the normal range of motion. Do the same on the lower extremity. Let the client assume a stable position and ask him to first flex the muscle to be examined and then to resist when you apply opposing force against that flexion. To test for the client’s major muscle tone and strength. With full resistance GRADE 0 1 2 3 4 5 RATIONALE 1 2 3 4 5 17.\ 18. b. Ask the client to turn head laterally against resistance. To assess for the MUSCLE TONE: a. To test for the STERNOCLEIDOMASTOID muscle.. no movement Full range of motion. The client is asked to allow an extremity (e. c.

Ask him to straighten leg against resistance. leave them on. apply pressure against forearm. To test for the HIP 1) QUADRICEPS: When client is sitting. e. Hand him an opaque card with which to shield one eye at a time. presenting an aromatic substance. apply downward pressure to thigh. f. CRANIAL NERVE II: OPTICE NERVE (Central Visual Acuity) 1) If the client is wearing corrective glasses or contact lens. Ask client to raise leg up from the table.PROCEDURE d. CRANIAL NERVE I: OLFACTORY NERVE 1) Occlude one nostril at a time and ask the client to sniff. (Use a Snellen Chart “E” for clients who cannot read letter. Remove only reading glasses. exerting firm pressure. place hand over midline of client’s shoulder. b. Ask client to straighten arm.) RATIONALE 1 2 3 4 5 . To test for the CRANIAL NERVES a. 19. Encourage the person to try the next smallest line also. Have the client raise shoulders against resistance. 2) GASTROCNEMIUS: Client sits holding shin of flexed leg. 2) TRICEPS: As client’s arm is flexed. 3) Ask the client to read through the chart to the smallest line of letters possible. To test for the shoulder (trapezius). 2) Position the client on a mark exactly 20 feet from the chart. 2) Ask the client to close his eyes and occlude one nostril at a time. To test for the ELBOW 1) BICEPS: Pull down on forearm as client attempts to flex arm.

Hold the card in good light about 35 cm from the eye. then back to center. and move it to each of the six position. Advance a light from the side and note the response. your finger) held about 7 to 8 cm (3 inches) from the nose. 5) Record the normal response as PERRLA DIAGNOSTIC POSITION TEST 1) Ask the client to hold the head steady and to follow the movement of your penlight only with the eyes. IV and VI: OCULOMOTOR. .4) Test near vision using a newspaper.g. Hold the target back about 12 inches so the client can focus on it comfortably. CRANIAL NERVE III. 2) SENSORY function: a) Ask the client to close his eyes then touch a cotton wisp to designated areas: forehead. Ask him to say “now” whenever the touch is felt. Hand the client an opaque card with which to shield one eye at a time. Then have the person shift the gaze to a near object (e. b) Try to separate the jaws by pushing down on the chin. 2) Darken the room and ask the person to gaze into the distance. 3) Gauge the pupil size in millimeters and compare with baseline. Progress clockwise. Assess also for pain. TROCHLEAR. hold it momentarily. and ABDUCENS NERVES 1) Gauge the pupil size in millimeters. d.. cheeks and chin. c. 4) Ask the person to focus on a distant object. CRANIAL NERVE V: TRIGEMINAL NERVE 1) MOTOR function: a) Assess the muscles of mastication by palpating the temporal and masseter muscles as the client clenches the teeth.

not the conjuctiva. e. With your head 1 to 2 feet from the client’s ear. b) . CRANIAL NERVE VIII: ACOUSTIC (Vestibulocochlear) NERVE VOICE TEST 1) Test on ear at a time while masking hearing in the other ear to prevent sound transmission around the head. peaceful). f. lift eyebrow. candy. 2) Shield your lips as you speak.g. bring a wisp of cotton from the side (to minimize defensive blinking) and lightly touch the cornea. hold it by the stem and strike the tines softly on the back of your hand. show teeth and puff cheeks. 2) SENSORY function a) Apply to the tongue a cotton applicator covered with a solution of sugar or salt. close eyes tightly (against your attempt to open them). Ask the client to identify the taste. Monday. exhale and whisper slowly some two syllable words (e.3) CORNEAL REFLEX: a) Let the client remove contact lenses. Press the client’s puffed cheeks in and note that the air should escape equally from both sides. With the client looking forward.. TUNING FORK TEST (Weber Test) 1) Activate the tuning fork. frown. CORNEAL NERVE VII: FACIAL NERVE 1) MOTOR fuction: a) Note mobility and facial symmetry as the client responds to these requests: smile.

Note the forward thrust in the midline as the client protrudes the tongue. i. and note the gag reflex. Also ask the client to say “bright. might” 20. the uvula and the soft palate should rise in the midline. CRANIAL NERVE XI: SPINAL ACCESSORY NERVE 1) Examine the sternocleidomastoid and trapezius muscles for equal size. and the tonsillar pillars should move medially. light. 2) Touch the posterior pharyngeal wall with a tongue blade. Also note that the voice sounds smooth and not strained. Check equal strength by asking the client to rotate the head forcibly against resistance applied to the side of the chin. g.2) Place a vibrating tuning fork in the midline of the client’s skull and ask if the tone sound the same in both ears or better in one. No wasting or tremors should be present. See Standard Protocol after the whole procedure. . CRANIAL NERVE XII: HYPOGLOSSAL NERVE 1) Inspect the tongue. Then ask the client to shrug the shoulders against resistance. and note pharyngeal movements as the client says “ahh” or yawns. h. CRANIAL NERVE IX and X: GLOSSOPHARYNGEAL and VAGUS NERVES MOTOR function 1) Depress the tongue with a tongue blade.

Cuff . Neck plate (flange) . It is performed more commonly as a prophylactic procedure so that secretions in there respiratory tract can be removed more effectively before a patient’s breathing is severely. the cuff can be deflated during the day.inflates with air inside the trachea to seal the trach wall.ENDOTRACHEAL AND TRACHEOSTOMY TUBE SUCTIONING Definition: An endotracheal tube is inserted by the physician or nurse with specialized education through either the mouth or the nose and into the trachea with the guide of a laryngoscope. for ties. . Because the tube passes through the epiglottis and glottis. Inner cannula . Parts Of A Tracheostomy Tube: 1. prevents movement and skin-breakdown secondary to pressure points. the nurse must have a thorough knowledge of sterile technique to care for and suction a tracheostomy. The tube terminates just superior to the bifurcation of the trachea into the bronchi. the client is unable to speak while it is in place. Obturator . Cuffed trach tubes are used predominately for patients who require mechanical ventilation with high pressures. 2. For patients requiring only nocturnal ventilation.a guide for positioning the actual trach tube. A tracheostomy is a surgical incision into the trachea to insert a tube through which the patient can breathe more easily and secretions can be removed. 3. Because the tracheostomy opens directly into the trachea. which is highly susceptible to infection.the "sleeve" inside of the tracheostomy tube that can be removed for cleaning. preventing aspiration and potential air leak around the cannula.

and up through the fenestration to the oropharynx.Contains an opening on the superior portion of the cannula. inner cannula. Metal tubes (Jackson tubes) are rigid. Single-cannula tube . This allows the patient to vocalize. Double-cannula tube . Double-cannula tubes are used mostly for children with thick. where air can travel from the vocal cords.Used mostly for infants and small children.The tube material is chosen on desired flexibility. Single-tubes are typically plastic and uncuffed. . Fenestrated tube . copious secretions. Cleaning the inner cannula avoids frequent tracheostomy tube (outer cannula) changes.Types of Tracheostomy Tubes: • • • • Composition . Shiley and Portex are plastic tubes. Polyvinyl chloride (PCV) tubes may be flexible or rigid. into the cannula. Can be cuffed or un-cuffed depending on the indication. Silicone tubes are very flexible.Contains a removable.

Indications: This procedure is indicated when the client: 1. Is dyspneic or appears cyanotic. infants and comatose patients). Is unable to cough and expectorate secretions effectively (e. . Has endotracheal or tracheostomy tube in place.g. 3.. 2. Makes light bubbling or rattling breath sounds that indicate the accumulation of secretions in the respiratory tract. and 4.

3. Moisture-resistant disposable bag . To remove secretions that obstruct the airway. Restrict each suction time to 10 seconds and total suctioning time to no more than 5 minutes. pulse. and 4. 6. 3. 8. Equipments: 1. Maintain the sterility of the dominant glove. For clients who do not have copious secretions. 4. Portable or wall suction machine with tubing and collection receptacle. normal saline. Sterile disposable container for fluids 5. Y-connector 11. For clients who have copious secretions. and syringe. Goggles and mask if necessary 8.Purposes: 1. Reapply supplementary oxygen as required during and after the procedure. 5. 2. breath sounds. Assess the client’s respirations. Sterile gloves 7. Sterile normal saline or water 6. if used. Sterile gauzes 12. To facilitate respiratory ventilation. color. Sterile suction catheter 10. 7. Sterile towel (optional) 3. suction catheter. 2. To prevent infection that may result from accumulated secretions in the respiratory tract. Replenish supplies in readiness for the next suction. hyperventilate the lungs with a resuscitation bag before suctioning. Special Considerations: 1. Use appropriate suction pressure. Gown (if necessary) 9. 4. increase the oxygen liter flow before suctioning. Rescuscitation bag (Ambu bag) connected to 100% oxygen 2. To obtain secretions for diagnostic purposes. and behavior before and after the procedure.

Obtain tracheostomy or endotracheal suctioning kit. Obtain tracheostomy or endotracheal suctioning kit. Identify the patient.PROCEDURE Assessment 1. 3. Assess the needs of the patient with a tracheostomy/endotracheal tube for suctioning. Wash your hands. Implementation 8. Assess the needs of the patient with a tracheostomy/endotracheal tube for suctioning. Planning 2. RATIONALE 1 2 3 4 5 . 7. Planning 6. Assessment 5. Identify the patient. Wash your hands. Implementation 4.

Identify the patient. Obtain tracheostomy or endotracheal suctioning kit. . 13. Provide privacy. 14. An explanation should also be given to the unresponsive patient.PROCEDURE Assessment 9. Planning 10. Assess the needs of the patient with a tracheostomy/endotracheal tube for suctioning. Explain the procedure carefully. 11. Wash your hands. RATIONALE 1 2 3 4 5 Ask the responsive patient to cough. Implementation 12.

Position the patient: Supine or mid-fowler’s with head slightly toward you if conscious. lateral position facing you if unconscious. 19. 17. RATIONALE 1 2 3 4 5 . usually low to medium.” c. remove needle. a. 16. 18.PROCEDURE 15. Turn on either the wall suction or the portable suction machine. Prepare 5 mL sterile saline in a syringe. Keep the suction regulated to a range of efficiency. Put on eye protection and mask. Place your thumb over the end of the unsterile tubing that is attached to the suction equipment and test for “pull. Establish a way patient can communicate. b. Test suction apparatus.

. Attach breathing bag to oxygen source. Instill saline into tracheostomy/endotracheal tube (if this is the policy). Open kit and prepare equipment. If the client has copious secretion. Attach breathing bag to tracheostomy/endotracheal tube and provide three breaths as the client inhales. Open and pour saline. Instead. RATIONALE 1 2 3 4 5 c. do not hyperventilate with a resuscitator. 23. Place drape or towel over patient’s chest. 22. Attach catheter to suction tubing. d. keep the regular O2 device on and increase the liter flow or adjust the FiO2 to 100% for several breaths before suctioning. and moisten catheter in normal saline solution. 21.PROCEDURE 20. b. a. Put on gloves.

Perform suctioning. Quickly but gently insert the catheter without applying any suction. Insert the catheter about 12. RATIONALE 1 2 3 4 5 C. D. Rinse the catheter with sterile water of normal saline solution. Apply intermittent suction for 5-10 seconds by placing the non-dominant thumb over the thumb port.5 cm (5 inches) for adults with Tracheostomy tube or until the client coughs or you feel resistance. Stop the procedure when there is persistent coughing. 25. B. E. Rotate the catheter by rolling it between you thumb and forefinger while slowly withdrawing it. Provide ventilation immediately after the suction catheter is removed (usually done by an assistant) to supply needed oxygen. A.PROCEDURE 24. .

34. 32. repeat steps 17a through d. and take nondisposable equipment to appropriate place for cleaning. Observe the patient for dyspnea and skin color changes. 31.PROCEDURE 26. Turn off the suction and listen for clear breath sounds. provide additional deep breaths of oxygen. and remove eye protection and mask. 30. 27. RATIONALE 1 2 3 4 5 . 28. 33. Disconnect the catheter from the suction tubing. If these symptoms of hypoxia occur. use the breathing bag to provide three or four deep breaths of oxygen. Discard disposable equipment. If the breathing sounds clear. Pull sterile glove over catheter to cover it. Wash your hands. 29. If the breathing sounds are not clear.

Patient resting comfortably. Respiratory rate and depth normal.PROCEDURE 35. . Breath sounds clear. Perform oral hygiene. Evaluate using the following criteria: a. Include the amount and description of suction returns and any other relevant assessments. Document the procedure and observations. RATIONALE 1 2 3 4 5 Evaluation 36. c. b. d. Documentation 37. Tracheostomy/endotracheal tube securely in place.

it forms a seal between the tracheostomy tube and the trachea. and the potential dangers associated with it. 30 minutes). 3. encircles the lower portion of the outer cannula of the tracheostomy tube.. When the client is eating or receiving oral medications. Maintain asepsis when suctioning. Purposes: Cuffed tracheastomy tubes are generally inflated: 1. If double-cuffed tubes are used. to prevent aspiration of oropharyngeal secretions. the cuff is inflated to form the seal. with the cuff inflated. 2. The cuff is so design that when it is properly inflated. The cuff. Withdraw the correct amount of air while the client inhales and while providing a positive pressure breath if ordered. preventing air from entering or escaping around the tube. Critical Elements: For cuff deflation: 1. purpose. it is essential to have a thorough understanding of the cuffed tube – its design. To give intelligent. At other times the cuff is deflated. Once the tracheostomy tube is in place in the patient’s trachea. The only route of effective air exchange. knowledgeable care. When the client is comatose. . The inflated cuff also reduces the possibility of aspiration of secretions into the lower trachea and bronchi. deflation and inflation must be done at regular intervals according to the manufacturer’s directions. During the first 12 hours after a tracheostomy.DEFLATING AND INFLATING A CUFFED TRACHEOSTOMY TUBE Definition: A cuffed trachestomy tube compounds the nursing care requirements of the patient in acute respiratory failure. principles of use. Nothing gets by the seal created in the trachea by the inflated cuff. 3. Suction the oropharngeal cavity adequately before cuff deflation. usually made of soft rubber.g. to prevent aspiration. and for a prescribed period of time following meals or medications (e. 2. to prevent leakage. and 4. When the client is being ventilated or receiving IPPB therapy. is the lumen of the tracheostomy tube.

Check the physician’s orders to determine when the cuffed RATIONALE 1 2 3 4 5 . 3. 2. Equipments: 1. Sterile three-way stopcock (optional) PROCEDURE 1. Manual resuscitator (Ambu bag) 6. For cuff inflation: 1. Clamp the inflation tube if required. Inflate the cuff on inhalation. Manometer specifically designed to measure cuff pressure (if available) 7. suction the lower airway. Follow the minimal leak 10. 5. Rubber-tipped hemostat 5. Document the exact amount of air used to inflate the cuff. Make sure the cuff pressure does not excess 15-20 mm Hg or 25 cm H2O. syringe 3. Stethoscope 4. If the cough reflex is stimulated after deflation. Equipment needed for suctioning the oropharyngeal cavity 2. 5.4.

Clients receiving positive pressure ventilation should be placed in a supine position so that secretions above the cuff site are moved up into the mouth. 6. 7. Some tubes have one-way valves that replace the hemostat. 2. and behavior. . Suction the oropharyngeal cavity before inflating the cuff. if the cough reflex is stimulated during cuff deflation. If a hemostat is clamping the cuff inflation tube. color. unclamp it. Discard the catheter after use. Assess the client’s respiration. Assist the client to a semi-fowler’s position unless contraindicated. Deflating the Cuff 4. 5. Attach the 5. pulse.or 10-ml syringe to the distal end of the inflation tube. breath should be inflated. Suction the lower airway with a sterile catheter. 3. making sure the seal is tight.

reinflate the cuff immediately. b. Assess the client’s respirations. Inflate the cuff on inhalation.PROCEDURE 8. If no leak is present. RATIONALE 1 2 3 4 5 . d. which indicate a leak. slowly remove 0. Listen for squeaking or gurgling sounds. Listen again for sounds. c. to create a minimal air leak. The minimal leak technique is designed to prevent tracheal damage and is performed as follows: a. Add the least amount of air following the manufacturer’s recommendations. and place your stethoscope on the client’s neck adjacent to the trachea.2-0. and suction the client as needed. If the client experiences breathing difficulties. Inflating the Tracheal Cuff 9.3 ml more air.

the amount of air withdrawn and/or injected. 10. Read the dial on the manometer. Measure the cuff pressure: a. nose. Determine the exact amount of air used to inflate the cuff. or tracheostomy site. and your assessments. Attach the cuff’s pillow port to the cuff pressure manometer. The cuff is inflated sufficiently when:   You cannot hear the client’s voice. 12. 13.  You hear a slight or no leak from the positive pressure ventilation when auscultating the neck adjacent to the trachea during inspiration. You cannot feel any air movements from the client’s mouth. Clamp the inflation tube with the hemostat if the tube does not have a one-way valve. Remove the syringe. Document the time of the deflation and/or inflation. 14.PROCEDURE e. RATIONALE 1 2 3 4 5 b. . The pressure should not exceed 15-20 mm Hg or 25 cm H2O. 11.

the Universal consists of three parts: the outer cannula (with cuff and pilot tube). the inner cannula. Cleaning solutions: hydrogen peroxide and sterile normal saline 3. Sterile nylon brush or pipe cleaners to clean the lumen of the inner cannula 4.CLEANING A DOUBLE-CANNULA TRACHEOSTOMY TUBE Definition: The Universal is most commonly used tracheostomy tube. Equipments: 1. and 2. To maintain the patency of the tube. Also known as the "double-luman" or "double-cannula" tube. Sterile bowls for the cleaning solutions 2. and the obturator. Sterile gauze squares or sterile cotton-tipped applicator sticks to clean the flange of the outer cannula 5. Prevent infection. Sterile gloves (1 pair and 1 glove or 2 pairs) 6. Clean glove . Purposes: 1.

Inspect the cannula for cleanliness and remove excess liquid from it before insertion. PROCEDURE 1. remove the inner cannula by gently pulling it out toward you in line with its curvature. 5. RATIONALE 1 2 3 4 5 4.Critical Elements: 1. 3. 5. Don an unsterile glove on the nondominant hand and a sterile glove on your dominant hand. Soak the inner cannula in the hydrogen peroxide solution for several minutes. Remove the gloves and replace with sterile gloves on both hands. With the nondominant hand. PROCEDURE 7. With your nondominant hand. 3. 6. unlock the inner cannula by turning the lock about 900 counterclockwise. Remove the tracheostomy dressing and inner cannula with your nondominant clean hand. 6. remove and discard the tracheostomy dressing. With the nondominant hand. 2. 2. Lock the inner cannula after insertions. RATIONALE 1 2 3 4 5 . Suction the entire length of the inner cannula prior to its removal. Suction the outer cannula before insertion the inner cannula. Suction the inner cannula before its removal. 4. Wear sterile gloves on both hands to clean the tube. which is wearing a clean glove.

Inspect the cannula for cleanliness by holding it at eye level and looking though it into the light. repeat steps 6. Clean the flange of the outer cannula if necessary. After rinsing the cannula. If encrustations are evident. and 9.8. gently tap it against the inside edge of the sterile solution bowl. Remove the cannula from the soaking solution Clean the lumen and entire inner cannula thoroughly. Suction the outer cannula. Dry the inside of the cannula by using two or three pipe cleaners twisted together. 12. 10. . 9. Agitate the cannula for several seconds in the sterile saline. using the pipe cleaners or brush moistened with sterile saline. using cotton-tipped applicators or gauze squares moistened with sterile saline. Do not dry the outer surface. 8. 13. 14. 11.

Grasp the outer flange of the inner cannula and insert the cannula in the direction of its curvation. 19. Clean the tracheostomy site.PROCEDURE 15. Gently pull on the inner cannula to ensure that the position is secure. Document removal. 18. RATIONALE 1 2 3 4 5 16. cleaning. and apply a new tracheostomy dressing. 17. and reinsertion of the cannula and all assessments. . Lock the inner cannula in place by turning the lock clockwise about 900 to an upright position.

Securely support the tracheostomy tube when cleaning it. 6. To maintain airway patency. Lock the inner cannula after insertion. Special Considerations: 1. Always fasten clean ties before removing soiled ties unless an assistant to hold the tracheostomy tube in place is available. . Suction the inner cannula before its removal. Remove the tracheostomy dressing and inner cannula with your non-dominant clean hand. tracheostomy care may only need to be done once or twice a day. depending on the client. Assess the status of the incision and surrounding skin. 3. Use noncotton-filled gauze square for cleaning and for the dressing. Inspect the cannula for cleanliness and remove excess liquid from it before insertion. To facilitate healing and prevent skin excoriation around the tracheostomy incision 4. Initially. 5. 4. 2. 7. Wear sterile gloves on both hands to clean the tube. 9. To promote comfort.PROVIDING TRACHEOSTOMY CARE Definition: The nurse provides tracheostomy care for the client with a new or recent tracheostomy to maintain patency of the tube and reduce the risk of infection. After the initial inflammation response subsides. 8. Purposes: 1. 2. To maintain cleanliness and prevent infection at the tracheostomy site 3. and when applying the dressing and tie tapes. a tracheostomy may need to be suctioned and clean as often as every 1 to 2 hours.

tracheostomy dressing. Explain what you are going to do. 5. small bottle brush or pipe cleaner. Implementation 4. Identify the patient. Obtain tracheostomy care kit. Planning 2. Provide privacy. RATIONALE 1 2 3 4 5 .Equipments: • • • • • Scissors 1 pair of clean gloves 1 pair of sterile gloves Hydrogen peroxide Normal saline • • • Tracheostomy kit (4x4-inch gauze. Although done routinely after tracheostomy care. twill tape or tracheostomy ties/collar) Oral care equipment Bag for soiled dressings PROCEDURE Assessment 1. 3. Wash your hands. cotton-tipped applicators. 6. assess the patient’s dressing for drainage or soiling. basin.

open first fold. Place your fingers around tube while you remove dressing. and remove old dressing and discard. RATIONALE 1 2 3 4 5 . Put on clean gloves. Remove gloves and wash hands. moistened swabs. Fold in half lengthwise. Put on sterile gloves.PROCEDURE 7. c. Hold tube while you remove dressing. 8. If 4x4 gauze. Note any redness or swelling. 12. 10. clean around edges of tracheostomy opening. Fold each end toward center. b. Cut and remove soiled tape. 9. With sterile. Secure the tube by gently holding in place. a. 11. b. Prepare the dressing using precut or 4x4 gauze squares: a. 13.

Perform oral care. It is helpful for you or the patient to hold a finger under the tape as it is tightened. c. d.PROCEDURE 14. Pass tape through opposite flange. a. 17. Bring tape around back of patient’s neck. Tie tape securely at side of neck. Dispose of equipment. 16. . RATIONALE 1 2 3 4 5 15. Thread tape through flange on one side. Check tube placement. Position new dressing. b.

RATIONALE 1 2 3 4 5 . Dressing and tapes clean and dry. and wash your hands. No secretions present. d. Absence of stale or foul-smelling breath. Tracheostomy tube securely in place.PROCEDURE 18. c. Remove gloves. e. b. Evaluation 19. Documentation 20. using the following criteria: a. Document procedure and any observations such as status of surrounding skin and amount of type of drainage. Evaluate. No redness or swelling present.

Forceps .ASSISTING WITH THE INSERTION AND REMOVAL OF A CHEST TUBE Definition: Chest tubes are inserted and removed by the physician with the nurse assisting. Sponges to clean the insertion area with antiseptic .A pleural drainage system with sterile drainage tubing and connectors .Alcohol sponges to clean the top of the vial . Split drain gauzes . if two tubes will be inserted . 1% lidocaine) . Another x-ray film of the chest is often taken after removal to confirm full lung expansion.A Y-connector. An x-ray film of the chest is generally taken 2 hours after tube clamping to determine full lung expansion.Tape (nonallergenic is preferable) . which includes .Sterile petrolatum gauze (optional) to place around the chest tube .Sterile gloves to remove the tube . A 1-in.Antiseptic (eg. Suture materials (eg. an x-ray film is taken to confirm the position of the tube. #25 gauge needle for the local anesthetic . A 10-ml syringe . A scalpel .Sterile gloves for the physician and the nurse . Several 4 x 4 gauze squares . Chest tubes are generally removed within 5-7 days. After the insertion. If neither occurs. Equipment: For tube insertion: . #22 gauge needle . the tube is removed.Clean gloves to remove the dressing .A vial of local anesthetic (eg.A sterile chest tube tray. A chest tube with a trocar . Two rubber-tipped clamps for each tube inserted . the tube clamps are removed. Drapes . Before removal. rubber-tipped clamps for 1-2 days to assess for signs of respiratory distress and to determine whether air or fluid remains in the pleural space. the tube is clamped with two large. If the client develops signs of respiratory distress or the film indicates pneumothorax. Both procedures require sterile technique and must be done without introducing air or microorganisms into the pleural cavity. A 5/8-in. 2-0 silk with a needle) For tube removal: . and chest drainage is maintained. povidone-iodine) .

diaphoresis. Chest movements. Inspect the dressing for excessive and abnormal drainage. such as bleeding or foul-smelling discharge.Scissors to cut the tape . faintness. with forceps and suture scissors . Leakage or blockage of a chest tube can seriously impair ventilation. Signs include sharp pain on the affected side. Dressing site. Level of discomfort. Diminished or absent breath sounds indicate inadequate lung expansion and recurrent pneumothorax after chest drainage is established. Palpate around the dressing site and listen for a crackling sound indicative of subcutaneous emphysema can result from a poor seal at the chest tube insertion site. Vital signs for baseline data and then every 4 hours. wide (nonallergenic is preferred) Intervention: Assessment Essential data include . Analgesics often need to be administered before the client moves or does deepbreathing and coughing exercises.Sterile swabs or applicators in sterile containers to obtain a specimen (optional) . vertigo. and blood-tinged sputum. . .. Clinical signs of pneumothorax before and after chest tube insertion. Auscultate bilaterally for baseline data. 2 or 3 in.A sterile suture removal set. excessive coughing. . A decrease in chest expansion on the affected side indicates pneumothorax.Sterile petrolatum gauze . It is manifested by a “crackling” sound that is heard when the area around the insertion site is palpated. pallor. .A moistureproof bag .An absorbent linen-saver pad . rapid pulse.Several 4 x 4 gauze squares . Breath sounds. dyspnea. . .Air-occlusive tape. weak.

while the physician anesthetizes the area. 3. Determine from the physician whether to have the bed in the supine position or semi-Fowler’s position. inserts the tube. invert the vial and hold it for the physician to withdraw the anesthetic.Chest Tube Insertion: PROCEDURE 1. 2. Open the chest tube tray and the sterile gloves on the overbed table. 5. RATIONALE 1 2 3 4 5 . Optional: Don sterile gloves. and then sutures the tube to the skin. Wrap a piece of sterile petrolatum gauze around the chest tube. Place drain gauzes around the insertion (one from the top and one from the bottom). After the physician dons the gloves and cleans the insertion area with antiseptic solution. Support and monitor the client as required. Wipe the stopper of the anesthetic vial with an alcohol sponge. 4. makes a small incision. Be sure to maintain sterile technique. Place several 4 x 4 gauze squares over these. Pour antiseptic solution onto the sponges. Assist the client to a lateral position with the area to receive the tube facing upward. either clamps the tube or immediately connects it to the drainage system.

Coil the drainage tubing. Assess the client’s vital signs every 15 minutes for the first hour following tube insertion and then as ordered. and tape the dressings. 10.PROCEDURE 6. Slowly exhale. eg. 11. RATIONALE 1 2 3 4 5 . 8. and secure it to the bed linen. 7. every hour for 2 hours. ask the client to a. b. When all drainage connections are completed. Tape the chest tube to the client’s skin away from the insertion site. 9. covering them completely. if donned. Take a deep breath and hold it for a few seconds. Tape the connections of the chest tube to the drainage tube and to the drainage system. Remove your gloves. then every 4 hours or as often as health indicates. ensuring enough slack for the person to turn and move.

Place rubber-tipped chest tube clamps at the bedside. 2. Open the sterile packages. 30 minutes before the tube is removed. Put the absorbent pad under the client beneath the chest tube. Assist the client to a semi-Fowler’s position or to a lateral position on the unaffected side. RATIONALE 1 2 3 4 5 . 13. Auscultate the lungs at least every 4 hours for breath sounds and the adequacy of ventilation in the affected lung. Administer an analgesic. 14. Assess the client regularly for signs of pneumothorax and subcutaneous emphysema. 5. RATIONALE 1 2 3 4 5 Chest Tube Removal: PROCEDURE 1. if ordered.PROCEDURE 12. 4. Ensure that the chest tube is securely clamped. and prepare a sterile field. 3.

c. b. place the sterile petrolatum gauze on a 4 x 4 gauze square. Hold the chest tube with forceps.PROCEDURE 6. 9. 7. RATIONALE 1 2 3 4 5 . Discard soiled dressings in the moistures-resistant bag.) strips of air-occlusive tape. While the physician is removing the tube. remove gloves and prepare three 15-cm (6 in. Wearing sterile gloves. The physician will a. Place the prepared petrolatum gauze dressing over the insertion site immediately after tube removal. d. Removed the soiled dressings. e. being careful not to dislodge the tube. Don sterile gloves. 8. which may contain drainage. Instruct the client to either inhale or exhale fully and hold the breath while removing the tube. Remove the underlying gauzes. Cut the suture holding the tube in place.

RATIONALE 1 2 3 4 5 Critical Elements of Assisting With The Insertion and Removal of a Chest Tube: . use a swab to obtain drainage from inside the chest tube. and any other assessment findings. 14. vital signs. 15.PROCEDURE 10. drainage system used. color. and infection. document the amount. completely cover it with the air-occlusive tape. If a specimen is required for culture and sensitivity. and the specimen obtained for culture. presence of bubbling. 13. document the insertion site. Assess the client regularly for signs of pneumothorax. every 15 minutes for the first hour following tube removal and then less often. For removal. while the physician holds the tube. if taken. subcutaneous emphysema. vital signs. After the gauze dressing is applied. 11. and consistency of drainage. Auscultate the client’s lungs every hour for the first 4 hours to assess breath sounds and the adequacy of ventilation in the affected lung. eg. breath sounds by auscultation. Document the date and time of chest tube insertion or removal and the name of the physician. For insertion. Monitor the vital signs. 12. and assess the quality of the respirations as health indicates.

For chest tube removal: Administer ordered analgesic before the procedure. Maintain sterile technique. skin color. For chest tube insertion: Apply appropriate dressings to the chest tube site. Place rubber-tipped chest tube clamps at the bedside. .- Assess the client’s vital signs. Quickly provide an airtight dressing over the insertion site after removal. and level of discomfort before and after chest tube insertion and removal. Tape all chest and drainage tube connections. Tape the chest tube to the client appropriately to prevent dislocation. bilateral breath sounds and chest movements. character of sputum. Clamp the chest tube securely before the procedure.

ESTABLISHING A CHEST DRAINAGE SYSTEM Definition: Before setting up a chest drainage system. Surgical aseptic technique is followed strictly when setting up chest drainage to prevent microorganisms from entering the system and subsequently entering the client’s pleural cavity. determine from the physician’s orders the type of system and whether suction is required. if ordered The drainage system If the agency does not supply partially assembled systems. Racks are supplied by the manufacturer for disposable unit systems Two rubber-tipped Kelly clamps Suction apparatus. Equipment: Sterile distilled water Adhesive tape Sterile clear plastic tubing Sterile tubing connectors A drainage rack. the following equipment is needed: For a one-bottle system: A sterile 2-L bottle A sterile short glass tube A sterile long glass tube A sterile rubber stopper with two holes For a two-bottle gravity system: Two sterile 2-L bottles Sterile clear plastic tubing Three sterile short glass tubes One sterile long glass tube Two sterile rubber stoppers with two holes .

Attach the rubber stopper with the glass tubes to the bottle. 3. Fill the bottle with about 300 ml of sterile distilled water 2. Make sure the long glass tube is submerged in the water about 2 cm (0.For a two-bottle suction system: Two sterile 2-L bottles Sterile clear plastic tubing Three sterile short glass tubes Two sterile long glass tube Two sterile rubber stoppers: one with two holes - Two sterile long glass tubes Three sterile rubber stoppers: with two holes. and one with three holes For a Pleur-evac or Argyle system Sterile distilled water A sterile 50-ml Asepto (bulb) syringe For a three-bottle system: Three sterile 2-L bottles Sterile clear plastic tubing Five sterile short glass tubes For a Thora-Drain III system: Bottle of sterile distilled water or normal saline.) RATIONALE 1 2 3 4 5 . Insert one short glass tube and one long glass tube through the rubber stopper.75 in. PROCEDURE One-Bottle System: 1. This system has larger caps through which water can be poured directly from the bottle.

8. RATIONALE 1 2 3 4 5 .seal bottle. 11. Place a strip of adhesive tape vertically on the drainage bottle to mark and assess the fluid level at prescribed periods. Securely tape all tubing connections. Insert two short glass tubes through the second rubber stopper.PROCEDURE 4. Place the bottle in the drainage rack on the floor beside the client’s bed. 10. and place both bottles in the drainage rack on the floor. 5. Follow steps 1-3 to set up the water-seal bottle. Connect clear plastic tubing to the long glass tube in the water. Two-Bottle Gravity System 9. attach the stopper securely to the collection bottle. 7. 6. and attach it to the nearer short glass tube in the collection bottle. Connect the clear plastic tubing to the long glass tube and to the client’s chest tube.

and place both bottles in the drainage rack on the floor. Follow steps 1-3 to set up the water-seal (and collection) bottle. Follow steps 6-7. Connect clear plastic tubing to the remaining short glass tube in the collection bottle and to the client’s chest tube. 15. Insert one long glass tube and two short glass tubes through the second stopper. Two Bottle Suction System: 14.PROCEDURE 12. attach the stopper securely to the suctioncontrol bottle. Fill the suction-control bottle with sterile distilled water to the level for the required suction. 16. RATIONALE 1 2 3 4 5 . 13.

18. Follow steps 6-7. RATIONALE 1 2 3 4 5 . b. and attach the stopper securely to the collection bottle. c. Connect the clear plastic tubing: a. Between the long glass tube in the water-seal bottle and the client’s chest tube. Three Bottle System: 19. Between the remaining short glass tube of the suctioncontrol bottle and the suction source. Insert two short glass tubes through the remaining two-hole stopper. Between the short glass tube in the water-seal bottle and one of the short glass tubes in the suction-control bottle. 21. 20.PROCEDURE 17. Insert two short glass tubes and one long glass tube through the three-hole rubber stopper. Follow steps 1-3 to set up the water-seal bottle.

Place the bottles on a drainage rack on the floor. Make sure the long glass tube will be submerge to the ordered length. Follow steps 6-7. 26. b. Between the long glass tube of the water-seal bottle and the nearer short glass tube of the collection bottle. 25. with the water-seal bottle in the middle. Between the remaining short glass tube of the suctioncontrol bottle and the suction source. then attach the stopper securely to this bottle. c. or Thoro-Drain III System RATIONALE 1 2 3 4 5 . Between the short glass tube of the water-seal bottle and the nearer short glass tube of the suction-control bottle. Between the remaining short glass tube of the collection bottle and the client’s chest tube. d. Add sterile distilled water to the sucton-control bottle.PROCEDURE 22. Connect the clear plastic tubing: a. Argyle. 24. 23. Pleur-evac.

do both. 33. 30. Then reattach the plastic connector or cap. RATIONALE 1 2 3 4 5 .) 29. If the physician has ordered suction. Use of an Asepto syringe is not necessary for this system. Using a 50-ml Asepto syringe with the bulb removed. fill the suction-control chamber with distilled water to the ordered level or 20-25 cm. (The Argyle system has two waterseal chambers. fill the water-seal chamber with sterile distilled water up to the 2-cm mark. remove the diaphragm (cap) on the suction-control chamber. or attach it to the bed frame. Using the 50-ml syringe if required. Remove the plastic connector or cap from the tube attached to the water-seal chamber. 32. The Thoro-Drain III System has a line indicating the amount of water required. 31. 28. Open the package unit. Place the system in the rack supplied. and replace the cap.PROCEDURE 27. Attach the longer tube from the collection chamber to the client’s chest tube.

If suction is ordered. Gentle bubbling indicates an appropriate suction level. . Set up the prescribed system correctly: Securely tape all tubing connections.PROCEDURE 34. Document the establishment of the chest drainage system and the nursing assessments. 37. Tape all tubing connections. allowing visibility of drainage through tubing connectors. but do not completely cover the entire tubing connectors with tape. and return it on. and the ends of tubing. If suction is used. and glass rods. 36. 35. Inspect the suction chamber for bubbling. If suction has not been ordered. tubing connectors. attach the remaining shorter tube to the suction source. RATIONALE 1 2 3 4 5 Critical Elements of Establishing A Chest Drainage System: Maintain sterility of the distilled water. Unclamp the client’s chest tube and inspect the system for air leaks. rubber stoppers. keep the shorter rubber tube unclamped. 38. the inside of collection bottles. inspect the suction chamber for continuous gentle bubbling to ensure appropriate suction level.

It is manifested by a “crackling” sound that is heard when the area around the insertion site is palpated. pallor. and blood-tinged sputum. . excessive coughing. Breath sounds. may be prohibited. Signs include sharp pain on the affected side. Dressing site. . A povidone-iodine swab . Level of discomfort. . A decrease in chest expansion on the affected side indicates pneumothorax. A sterile #18 or #20 gauge needle . Vital signs for baseline data and then every 4 hours. Chest movements. if ordered Specimen supplies. such as bleeding or foul-smelling discharge. . A needle protector . . faintness. Palpate around the dressing site and listen for a crackling sound indicative of subcutaneous emphysema can result from a poor seal at the chest tube insertion site. such as milking a chest tube to maintain patency. Inspect the dressing for excessive and abnormal drainage. A 3-or 5-ml syringe . Equipment: Two rubber-tipped Kelly clamps A sterile petrolatum gauze A sterile drainage system Antiseptic swabs Sterile 4 x 4 gauzes Air-occlusive tape A mechanical chest tubing stripper. if needed: . A laboratory requisition Intervention: Essential data include .MONITORING A CLIENT WITH CHEST DRAINAGE Definition: Policies and procedures vary considerably from agency to agency in regard to chest drainage interventions. rapid pulse. diaphoresis. Certain interventions. Analgesics often need to be administered before the client moves or does deepbreathing and coughing exercises. Auscultate bilaterally for baseline data. Diminished or absent breath sounds indicate inadequate lung expansion and recurrent pneumothorax after chest drainage is established. Leakage or blockage of a chest tube can seriously impair ventilation. vertigo. dyspnea. A label for the syringe . . Clinical signs of pneumothorax before and after chest tube insertion. weak. The nurse must therefore review agency policies before intervening.

Keep an extra drainage system unit available in the client’s room. unless the chest tubes are clamped. c. In most agencies the physician is responsible for changing the drainage system except in emergency situations. 4. Keep the drainage system below chest level and upright at all times. to clamp the chest tube in an emergency. Remove the clamps. In these situations: a. RATIONALE 1 2 3 4 5 .PROCEDURE Safety Precautions: 1. Reestablish a water-sealed drainage system. if leakage occurs in the tubing. 2. eg. Keep one sterile petrolatum gauze within reach at the bedside to use with an air-occlusive material if the chest tube becomes dislodged. Clamp the chest tubes b. and notify the physician. such as malfunction or breakage. 18-cm (6-7-in. Keep two 15.) rubber-tipped Kelly clamps within reach at the bedside.

d. or a towel. If the chest tube becomes disconnected from the drainage system: a. If the chest tube becomes dislodged from the insertion site: a. Tape the dressing with air-occlusive tape. Remove the dressing. your hand. Notify the physician immediately e. b. d. c. Cover the site with sterile 4 x 4 gauze squares. Clamp the chest tube close to the insertion site with two rubber-tipped clamps placed in opposite directions. b. Unclamp the tube as soon as possible.PROCEDURE 5. Assess the client for respiratory distress every 15 minutes or as health indicates. Assess the client closely for respiratory distress. Quickly clean the ends of the tubing with an antiseptic. c. and tape them securely. Have the client exhale fully. e. RATIONALE 1 2 3 4 5 . and immediately apply pressure with the petrolatum gauze. reconnect them. 6.

b. Ask the client to take several deep breaths. Commercial systems cannot be emptied. RATIONALE 1 2 3 4 5 c. If the drainage system is accidentally tipped over: a. Immediately return it to the upright position. Assess the client for respiratory distress.PROCEDURE 7. . d. Notify the nurse in charge and the physician. Do not empty a drainage bottle unless there is an order to do so. 8.

until you reach the end of the tubing. reposition your hands farther along the tubing. milking of only short segments of the tube may be specified. Compress the tube with the thumb and forefinger of your other hand and milk it by sliding them down the tube. Milk or strip the chest tubing as ordered and only in accordance with agency protocol. To milk a chest tube. Check that all connections are secured with tape. or follow these steps: a. or hand lotion. moving away from the insertion site. Lubricate about 10-20 cm (4-8 in.MONITORING AND MAINTAINING THE DRAINAGE SYSTEM PROCEDURE 1. securely stabilize and pinch the tube at the insertion site. c. Always verify the physician’s orders before milking the tube. RATIONALE 1 2 3 4 5 . 2. b. d.) of the drainage tubing with lubricating gel. Too vigorous milking can create excessive negative pressure that can harm the pleural membranes and/ or surrounding tissues. With one hand. If the entire tube is to be milked. use a mechanical stripper. soap. or hold an alcohol sponge between your fingers and the tube. and repeat steps a-c in progressive overlapping steps.

To check for fluctuation in suction systems. 4. In gravity drainage systems. date. Inspect the drainage in the collection container at least every 30 minutes during the first 2 hours after chest tube insertion and every 2 hours thereafter. Normally. temporarily disconnect the system. Note any sudden change in the amount or color of the drainage. check for fluctuation (tidaling) of the fluid level in the water-seal glass tube of a bottle system or the water-seal chamber of a commercial system as the client breathes. If drainage exceeds 100 ml/hour or if a color changes indicates hemorrhage. and drainage level on a piece of adhesive tape affixed to the container. Then observe the fluctuation. Every 8 hours mark the time. notify the physician immediately. or mark it directly on a disposable container. the fluid line remains constant. In suction drainage systems. . RATIONALE 1 2 3 4 5 5. fluctuations of 5-10 cm occur until the lungs has reexpanded.PROCEDURE 3.

Check for intermittent bubbling in the water of the water-seal bottle or chamber. Inspect the drainage tubing for kinks or loops dangling below the entry level of the drainage system. Check for gentle bubbling in the suction-control bottle or chamber. Inspect the air vent in the system periodically to make sure it is not occluded. 8. RATIONALE 1 2 3 4 5 . 7. 9. A vent must be present to allow air to escape.PROCEDURE 6.

Check the tubing connection sites. ie. ie. d. Chest tube clamping must be done only for a few seconds at a time. Continuous bubbling that persists indicates an air leak. in the drainage system below the clamp. b. It may be either at the insertion site or inside the client. clamp the chest tube near the insertion site and see if the bubbling stops while the client takes several deep breaths. follow step 21. follow step 20. a. between the clamp and the client. RATIONALE 1 2 3 4 5 .Detecting Air Leaks: Continuous bubbling in the water-seal collection chamber normally occurs for only a few minutes after a chest tube is attached to drainage. since fluid and air initially rush out from the intrapleural space under high pressure. If bubbling continues. The source of the air leak is above the clamp. c. If bubbling stops. The source of the air leak is below the clamp. Tighten and retape any connection that seems loose. To determine the source of an air leak follow the next steps sequentially. If bubbling continues. PROCEDURE 1.

To remedy this situation. the leak is at the insertion site. Unclamp the tube and palpate gently around the insertion site. notify the physician. 3. Move the clamp a few inches farther down and keep moving it downward a few inches at a time. b. and monitor the client for signs of respiratory distress. To determine whether the air leak is at the insertion site or inside the client: a. To locate an air leak below the chest tube clamp: a. Each time the clamp is moved. If tubing continues after the entire length of the tube is . The bubbling will stop as soon as the clamp is placed between the air leak and the water-seal drainage. apply a petrolatum gauze and a 4 x 4 gauze around the insertion site and secure these dressings with adhesive tape. Seal the leak when you locate it by applying tape to that portion of the drainage tube. b. it is inside the client and may indicate a dislodged tube or a new pneumothorax. a new disruption of the pleural space. RATIONALE 1 2 3 4 5 c. In this instance leave the tube unclamped. If the bubbling stops.PROCEDURE 2. If the leak is not at the insertion site. check the water-seal collection chamber for bubbling.

6. and splint the tube insertion site with a pillow or with a hand to minimize discomfort. Reposition the client every 2 hours. Client Care: 4. To remedy this situation the drainage system must be replaced and the physician notified. place rolled towels beside the tubing. Assist the client with range-of-motion exercises of the affected shoulder three times per day to maintain joint mobility. Note whether chest expansion is symmetric.). palpate the chest for thoracic expansion.clamped.5-5 cm (1-2 in. 7. As the client inhales. the air leak is in the drainage device. . Place your hands together at the base of the sternum so that your thumbs meet. Encourage deep-breathing and coughing exercises every 2 hours. 5. While the client takes deep breaths. When the client is lying on the affected side. Have the client sit upright to perform the exercises. your thumbs should separate at least 2.

label the syringe. Keep the water-seal unit below chest level and upright. Attach rubber-tipped forceps to the client’s gown for emergency use. and insert the needle into the diaphragm. Allow it to dry. b. Take a Specimen of Chest Drainage: 9. Use a povidone-iodine swab to wipe the self-sealing diaphragm on the back of the drainage collection chamber. since these systems are equipped with-sealing ports. Attach a sterile #18 or #20 gauge needle to a 3. Disconnect the drainage system from the suction apparatus before moving the client. If a specimen is required: a. c. and make sure the air vent is open. attach the needle protector. remove the clamp as soon as possible. and send it to the laboratory with the appropriate requisition form. If it is necessary to clamp the tube. b. Specimens of chest drainage may be taken from a disposable chest drainage system. c. d. When transporting and ambulating the client: a. RATIONALE 1 2 3 4 5 . Aspirate the specimen.or 5-ml syringe.PROCEDURE 8.

and an extra drainage system available for emergency situations. Know what to do if the chest tube becomes disconnected or dislodged or if the drainage system tips over. Always keep the drainage system below chest level. Keep two rubber-tipped Kelly clamps. one sterile petrolatum gauze. Prevent tubing obstruction. Empty drainage systems only if ordered. Make sure there is fluctuation or bubbling in the appropriate bottle or chambers. Keep air vents open. .Critical Elements of Monitoring A Client With Chest Drainage: • • • • • • • • • Assess the client for signs of pneumothorax. Make sure the system is airtight.


Purpose: To support and protect injured bones and soft tissue, reducing pain, swelling, and muscle spasm, maintains alignment and prevents movement of the bones while it heals.

Special Considerations: • Before and after cast application: 1. Assess for signs of restricted circulation 2. Take the client’s pulse rate, respiratory rate, and blood pressure • • • • • • • Administer ordered analgesics before cast application Before cast is applied, remove clothing from the body area and rings from fingers of the affected limb Ensure safe storage of the client’s valuables Wash the skin area to receive the cast and dry it thoroughly if ordered Stabilize and support the limb appropriately during cast application. Remove excess cast material from client’s skin after application. Document assessment and interventions.

Equipment: • • Rolls of cast materials Plastic –lined bucket of water at the prescribed 1. • • • • • • Tepid water for Plaster of Paris and water activated • • • • • • 2. cast or A thermostatically controlled hydro collator or a boiler or cooking pot with a temperature- regulating thermometer for a thermoplastic cast. Stockinet Cotton sheet wadding or padding Felt padding (optional) Plaster Splints (optional) Moisture- resistant drapes Rubber gloves Plastic aprons Water- soluble lubricant Plaster knife Large bandage scissors Pillows Damp cloth 1 2 3 4 5 Cool water at 26 C (80 F) for polyester and cotton


PROCEDURE 1. Explain the procedure to the client, including the length of time the cast material requires for drying. Explain that the cast may feel warm during and after the application 2. Provide an analgesic as ordered 3. Assist the client into a comfortable sitting or lying position 4. Remove clothing from the body area and rings from fingers of the affected limb and give them to a family member or store safely in a locked safe. 5. Support the part to receive the cast


PROCEDURE 6. Wash the skin area, and dry it thoroughly, if ordered. If there is no open wound, powder may be applied. 7. Provide stockinet of the correct size if used, and cut it several inches longer than the length of the extremity so that it will extend beyond the plaster edges. Then roll the stockinet to facilitate application. 8. Provide sheet wadding and felt pads as needed. Usually 2- 3 layers are applied. 9. Provide gloves for the physician prior to application of the cast material 10. Hand the physician the casting material or place the material within the physicians reach. Preparation of cast material varies depending on the type of casting material used 11. Squeeze a generous amount of water-soluble lubricant on the physicians gloves as requested







and cast material. grasp the client’s toes for a leg cast or fingers for an arm cast. pull the stockinet out over the proximal and distal cast opening edges. After the cast is applied. Remove any excess cast material deposited accidentally on the client’s skin. 13. Gather and dispose the used materials appropriately 18. padding. With one hand. Provide firm support for the cast. Support the limb while the physician applies the stockinet. while the physician secures it in place with one or two layers of cast material. 15.PROCEDURE 12. Document . RATIONALE 1 2 3 4 5 16. Assess the client with special reference to the cast. and with the other hand support beneath the limb areas on which the physician is not working. 14. 17.

3.CLIENT CARE IMMEDIATELY AFTER A CAST APPLICATION Equipment: • Soft. pliable pillows RATIONALE 1 2 3 4 5 PROCEDURE 1. Control swelling by elevating arms or legs on pillows or. for leg fracture. Immediately after the cast is applied. Support the cast in the palms of your hands rather than your fingertips 4. place it on pillows. Report excessive swelling and indications of neurovascular impairments to the physician or nurse in charge. by elevating the foot of the bed 5. Avoid using plastic or rubber pillows. Apply ice packs to a hip spica cast . Assess the toes and fingers for nerve or circulatory impairments every 30 mins for several hours following application and then every 3 hours for the first 24-48 hours or until all signs and symptoms of impairment are negative 2. 6.

infrared lamps. be alert to changes in temperament. 11. Do not disregard the cessation of persistent pain or discomfort complaints 14. 12. Never ignore any complaints of pain. Outline the stained area every 8 hours. Monitor drainage for 24-72 hours after surgery. or fussiness. Document RATIONALE 1 2 3 4 5 . restlessness. If patient is unable to communicate. hairdryers. Give pain medications selectively 13. This means including fans.PROCEDURE 7. and electric heaters 10. Check agency policy about the recommended turning frequency for clients with different kinds of cast 9. burning or pressure. Avoid the use of artificial means to facilitate drying. Expose the cast to the circulating air 8.

confined patients. exercises. signs of neurovascular problems. It may be necessary to use a duck billed cast bender to bend cast edges that may irritate the skin 2. “petal” rough cast edges. . Cover rough edges of the cast when it is dry. For bed. ways to move safely. ways to handle itching Equipment: • • • • Rubbing alcohol Mineral. activity allowed. If the stockinet has not been used to line the cast. olive. elevating the involved extremity. Wash crumbs of plaster from the skin with a damp cloth and feel along the cast edges or areas that press into the client’s skin. provide skin care over all bony prominences and turn the clients at least every 4 hours Keep the cast clean and dry Encourage clients to move toes or fingers of the casted extremity frequently Provide necessary instructions about cast care. or baby oil to apply to the skin after cast removal Adhesive tape Scissors • • • • Damp washcloth for Plaster of Paris Warm water and a mild soap for synthetic casts Pillows Fracture pan RATIONALE 1 2 3 4 5 PROCEDURE 1.CONTINUING CARE FOR CLIENT’S WITH CASTS Special Considerations: • • • • • Remove crumbs of plaster from the skin. “petal” the edge with small strips of adhesive tape.

Place a bib or towel over a body cast to catch spills. or baby) b. When cast is removed. remove this debris gently and gradually by: a. flaky and encrusted skin is observed. olive. allow the area to air dry. If a spill does wet the cast. Use a fracture bedpan for people with long leg. 7. Caution the client not to rub the area too vigorously d. Tub baths and showers are contraindicated. POP cast is kept clean by wiping it with a damp cloth. Check the cast daily for foul odors 4. hip spica.PROCEDURE 3. Apply oil (mineral. Discourage the patient from using long sharp objects to scratch under the cast 5. or body casts. Soak the skin with warm water and dry it c. dry. repeat steps a and b for several days Keeping the Cast Clean and Dry 6. RATIONALE 1 2 3 4 5 .

keep the cast supported on pillows while the client is on bed pan. support both extremities and the back on pillows so that they are as high as the buttocks 11. 10. thoroughly clean and dry the perineal area . When removing the bedpan. tuck plastic or other waterproof material around the top of a long leg cast or in around the perineal cutout. Before placing the client on the bed pan. For clients with hip spica casts. For people with long leg casts.PROCEDURE 8. hold it securely while the client is turning or lifting the buttocks. Remove plastic when elimination is completed RATIONALE 1 2 3 4 5 9. After removing the bedpan.

Dry thoroughly to prevent skin maceration and ulceration under the cast. be immersed in water if polypropylene stockinet and padding were applied. Then use a handheld blow-dryer on the cool or warm setting. Synthetic casts: Synthetic casts can be cleaned readily and may. directing the air stream in a sweeping motion over the exterior of the cast for about 1 hour or until the client no longer feels a cold clammy sensation like that produced by a wet bathing suit. with the physician’s permission. Thoroughly rinse the soap from the cast c. Wash the soiled area with warm water and a mild soap RATIONALE 1 2 3 4 5 b.PROCEDURE 12. First blot excess water from the cast with a towel. the cast and underlying padding and stockinet must be dried thoroughly. a. d. If the cast is immersed in water. .

. encourage active ROM exercises for all joints on the affected extremities. Plan and implement a turning schedule incorporating all possible positions. c. Body alignment is maintained RATIONALE 1 2 3 4 5 14. Body parts press against the cast edges as little as possible. Place pillows in such a way that: a. etc. elbows. as well as on the joints proximal and distal to the cast 16. are protected from pressure against bed surface.PROCEDURE Turning and Positioning Clients 13. b. heels. Unless contraindicated. Toes. Exercise 15. Encourage the client to move the toes and/or fingers of the casted extremity as frequently as possible. .

. Teach isometric exercises on the client’s unaffected limb before the person applies it to the affected limb. teach isometric (muscle setting) exercises.PROCEDURE 17. 19. With the physician’s approval. Document assessments and nursing implementations on the appropriate records. RATIONALE 1 2 3 4 5 18. Demonstrate muscle palpation while the client is carrying out the exercise.

thus negating the traction To apply and maintain the correct amount of traction. all traction weights should be hanging freely and the ropes should not touch any part of the bed. . The line of pull determines the position and alignment of the body as prescribed by the physician Traction should always be applied while the client is in proper body alignment in a supine position Equipment: • • • Protective skin devices. and prevent infection Guidelines: • • • • All traction should have a counter traction to prevent the client from being pulled by the force of traction against the pulleys or the bed.g. E. e. such as every 2 hours 2. Inspect the traction apparatus regularly. heel protectors Trapeze Rubbing alcohol • • • Antiseptic agent Sterile gauze dressing Picking forceps RATIONALE 1 2 3 4 5 PROCEDURE 1. Provide protective devices and measures to safeguard the skin. The traction force should follow an established line of pull.TRACTION CARE Purpose: • To apply a continuous pulling force to an extremity or body part. pillows. heel protectors. whenever you are at the bedside or at prescribed intervals. etc) massage the skin. maintain its alignment.g.

PROCEDURE 3. Remove weights first. e. Rewrap the limb and slowly reattach the weights 7. if the client has balanced suspension traction 5. check agency policy about any orders required. • • • • • Carefully inspect the site Use sterile technique Remove crusts with a rolling technique Cover sites with a sterile barrier Determine the frequency of care by the amount of drainage RATIONALE 1 2 3 4 5 .g. Provide pin site care and this varies with different hospital protocols. then unwrap the bandage and provide skin care. Non adhesive skin traction is intermittent and can be removed. 6.. Provide a trapeze to assist the client to move and lift the body for back care if the person is unable to turn. Maintain the client in supine position unless there are other orders 4. Do not remove skeletal and adhesive skin traction.

RATIONALE 1 2 3 4 5 9.PROCEDURE 8. Document . Teach the client appropriate exercises 10. Teach client deep breathing and coughing.

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